Oncologic Uses of White Blood Cell Colony Stimulating Factors

This policy covers white blood cell colony‑stimulating factors (e.g., filgrastim, peg‑filgrastim, biosimilars, tbo‑filgrastim and Onpro/Onbody formulations) for oncologic uses such as primary prophylaxis of chemotherapy‑induced febrile neutropenia in patients with non‑myeloid malignancies and continuation therapy for members already deriving benefit. Coverage requires dosing, frequency, and duration consistent with FDA labeling or other authoritative compendia (or peer‑reviewed evidence for supported off‑label uses), and generally prohibits step therapy for FDA‑approved cancer indications unless an interchangeable biosimilar/generic is available; benefit plan and state‑specific mandates (e.g., IBAC, Arkansas, Ohio) and other policy exclusions apply. Non‑preferred agents may be allowed for intolerance, contraindication, failure of preferred agents, documented shortages/recalls, or when the patient cannot self‑administer and lacks a caregiver.

"Therapy is covered when proven effective for the relevant diagnosis or procedure based on peer‑reviewed scientific literature or nationally recognized authoritative references."